But the Pain Remains: A Response to Verpaelst

Commentaire / CommentaryLes personnes aux prises avec la douleur chronique évitent parfois d’exprimer leur douleur ouvertement, par crainte d’être stigmatisées. Les professionnels de la santé travaillant auprès de cette clientèle peuvent également avoir de la difficulté à accepter la nature persistante de la douleur de leurs clients. À travers sa peinture, Verpaelst aide à surmonter ces difficultés.People who experience chronic pain often refrain from expressing their pain overtly due to fear of stigmatization. Health professionals working with these persons may also find it challenging to face the persistent nature of their clients’ pain. Through his painting, Verpaelst helps to overcome these difficulties

La priorisation des demandes en ergothérapie dans les programmes de soutien à domicile

Les demandes de service en ergothérapie à domicile au Québec sont priorisées en fonction du niveau d’urgence, mais cette pratique n’est pas standardisée et son impact sur l’accès aux services est incertain. Cette thèse, constituée de deux études interreliées, porte sur les processus de priorisation des demandes en ergothérapie dans les programmes de soutien à domicile. La première étude a pour but de décrire en détail les processus utilisés pour prioriser les demandes et d’investiguer l’association entre ces processus et la longueur des listes d’attente. Pour ce faire, un sondage a été réalisé auprès de la personne qui gère la liste d’attente en ergothérapie dans 55 programmes de soutien à domicile. Malgré une grande variabilité dans les processus de priorisation, la tendance générale indique que les problèmes affectant la sécurité et les activités à l’intérieur du domicile sont fortement priorisés alors que les problèmes affectant la qualité de vie et les activités à l’extérieur du domicile sont peu prioritaires. L’écart entre les temps d’attente en fonction des niveaux de priorité est important, avec un temps d’attente médian de 2 jours pour les demandes urgentes et de 18 mois pour les demandes non prioritaires. Les programmes qui utilisent des balises de temps d’attente maximal ont des listes d’attente significativement plus courtes que les programmes qui n’utilisent aucun mécanisme pour allouer des services aux clients non prioritaires. La deuxième étude vise à comparer les opinions des ergothérapeutes à domicile, des personnes âgées et des personnes ayant une déficience physique sur l’importance relative des principaux critères utilisés pour prioriser les demandes. Un sondage composé de mises en situation par choix de scénarios prioritaires démontre une différence significative entre les priorités des trois groupes de répondants. Les ergothérapeutes (n=241) priorisent fortement les personnes qui ont chuté alors que les personnes âgées (n=226) et celles ayant une déficience physique (n=247) priorisent principalement les personnes qui ne peuvent sortir de leur domicile. Des entrevues qualitatives avec un sous-groupe de 30 participants révèlent que les ergothérapeutes priorisent les problèmes relatifs à la sécurité en raison de contraintes institutionnelles liées au manque de ressources, mais qu’ils expriment d’importantes tensions éthiques à cet égard. Les personnes âgées et celles ayant une déficience physique priorisent en fonction d’autres enjeux comme l’autonomie, la dignité, l’inclusion, la participation et la liberté. Elles réclament donc des critères de priorisation qui reflètent une vision plus globale de la santé et des services de santé. Les résultats de la thèse soulignent la nécessité d’améliorer les processus de priorisation des demandes en ergothérapie à domicile et suggèrent certaines pistes pour y parvenir. Notamment, il serait souhaitable de porter une attention particulière au traitement des demandes non prioritaires, de consulter la clientèle cible des services sur les critères de priorisation et d’adopter une vision élargie des interventions, au-delà de la sécurité à domicile. La prise de conscience des enjeux et défis sous-jacents à la priorisation pour les ergothérapeutes et leur clientèle cible permet ainsi de viser un accès plus juste aux services d’ergothérapie à domicile.Referrals to home care occupational therapy services in the province of Quebec are prioritized according to urgency. However, this practice is not standardized and its impact on access to care is uncertain. This thesis, consisting of two related studies, investigates referral prioritization processes for occupational therapy services in home care. The first study aims to describe in detail the processes that are used to prioritize referrals and to examine the associations between these processes and the the wait for services. We conducted a survey with the person who manages the occupational therapy waiting list in 55 home care programmes. Referral prioritization criteria vary between programmes, but there is a general tendency for problems related to safety and activities inside the home to receive high priority whereas problems related to quality of life and activities outside the home are not prioritized. Priority levels are highly associated with wait times; urgent referrals wait for a median of 2 days and low priority referrals wait for a median of 18 months. Programmes that have guaranteed maximum wait times have significantly shorter waiting lists than programmes that do not use any strategies to allocate services to low priority clients. The second study aims to compare the opinions of home care occupational therapists, elderly people and persons with disabilities on the relative importance of the main criteria that are used to prioritize referrals. A survey consisting of fictional referral prioritization tasks revealed a significant difference between the priorities of the three groups of respondents. Occupational therapists (n=241) strongly prioritize persons who have fallen whereas elderly people (n=226) and persons with disabilities (n=247) mainly prioritize people who are unable to exit the home. Qualitative interviews with a subgroup of 30 participants revealed that occupational therapists prioritize issues related to home safety due to institutional constraints and lack of resources, but experience ethical tensions in doing so. Elderly people and persons with disabilities prioritize other issues such as independence, dignity, inclusion, participation and freedom. They call for referral prioritization criteria that reflect a broader view of health and healthcare. The findings from this thesis highlight the need to improve referral prioritization processes in home care occupational therapy and suggest possible avenues to do so. For example, it would be beneficial to use strategies to allocate services to low priority clients, to consult the target clientele on referral prioritization criteria and to adopt a broader view of occupational therapy interventions, beyond home safety. By considering the various issues and challenges underlying referral prioritization for home care occupational therapists and their clientele, we can target solutions to improve equitable service allocation of home care occupational therapy

Prioritization of Referrals in Outpatient Physiotherapy Departments in Québec and Implications for Equity in Access

In the context of long waiting time to access rehabilitation services, a large majority of settings use referral prioritization to help manage waiting lists. Prioritization practices vary greatly between settings and there is little consensus on how best to prioritize referrals. This paper describes the prioritization processes for physiotherapy services in Québec and its potential implications in terms of equity in access to services. This is a secondary analysis of a survey of outpatient physiotherapy departments (n=98; proportion of participation was 99%) conducted in 2015 across publicly funded hospitals in Québec. In many settings, persons with acute orthopaedic conditions were prioritized while chronic conditions were given a lower priority. There were 72 different combinations of prioritization criteria used in outpatient physiotherapy departments. Variability was also observed in the type of personnel involved in the prioritization process, the number of priority levels used to rank the referrals and the source of information used to prioritize referrals. These results highlight potential issues regarding equity in access to physiotherapy services: the prioritization of persons with acute conditions to the detriment of those with chronic conditions, the lack of consensus on a fair prioritization process and the importance to adequately assess patients’ needs for treatment. Further research and interventions on prioritization criteria and processes are needed to ensure equitable access to physiotherapy services, especially in the public sector

Staphylococcus aureus infective endocarditis versus bacteremia strains: Subtle genetic differences at stake

AbstractInfective endocarditis (IE)(1) is a severe condition complicating 10–25% of Staphylococcus aureus bacteremia. Although host-related IE risk factors have been identified, the involvement of bacterial features in IE complication is still unclear. We characterized strictly defined IE and bacteremia isolates and searched for discriminant features. S. aureus isolates causing community-acquired, definite native-valve IE (n=72) and bacteremia (n=54) were collected prospectively as part of a French multicenter cohort. Phenotypic traits previously reported or hypothesized to be involved in staphylococcal IE pathogenesis were tested. In parallel, the genotypic profiles of all isolates, obtained by microarray, were analyzed by discriminant analysis of principal components (DAPC)(2). No significant difference was observed between IE and bacteremia strains, regarding either phenotypic or genotypic univariate analyses. However, the multivariate statistical tool DAPC, applied on microarray data, segregated IE and bacteremia isolates: IE isolates were correctly reassigned as such in 80.6% of the cases (C-statistic 0.83, P<0.001). The performance of this model was confirmed with an independent French collection IE and bacteremia isolates (78.8% reassignment, C-statistic 0.65, P<0.01). Finally, a simple linear discriminant function based on a subset of 8 genetic markers retained valuable performance both in study collection (86.1%, P<0.001) and in the independent validation collection (81.8%, P<0.01). We here show that community-acquired IE and bacteremia S. aureus isolates are genetically distinct based on subtle combinations of genetic markers. This finding provides the proof of concept that bacterial characteristics may contribute to the occurrence of IE in patients with S. aureus bacteremia

Extending the clinical spectrum of X-linked Tonne-Kalscheuer syndrome (TOKAS):new insights from the fetal perspective

INTRODUCTION: Tonne-Kalscheuer syndrome (TOKAS) is a recessive X-linked multiple congenital anomaly disorder caused by RLIM variations. Of the 41 patients reported, only 7 antenatal cases were described.METHOD: After the antenatal diagnosis of TOKAS by exome analysis in a family followed for over 35 years because of multiple congenital anomalies in five male fetuses, a call for collaboration was made, resulting in a cohort of 11 previously unpublished cases.RESULTS: We present a TOKAS antenatal cohort, describing 11 new cases in 6 French families. We report a high frequency of diaphragmatic hernia (9 of 11), differences in sex development (10 of 11) and various visceral malformations. We report some recurrent dysmorphic features, but also pontocerebellar hypoplasia, pre-auricular skin tags and olfactory bulb abnormalities previously unreported in the literature. Although no clear genotype-phenotype correlation has yet emerged, we show that a recurrent p.(Arg611Cys) variant accounts for 66% of fetal TOKAS cases. We also report two new likely pathogenic variants in RLIM, outside of the two previously known mutational hotspots.CONCLUSION: Overall, we present the first fetal cohort of TOKAS, describe the clinical features that made it a recognisable syndrome at fetopathological examination, and extend the phenotypical spectrum and the known genotype of this rare disorder.</p